Preventive Services: Covered Contraceptive Products for Oregon
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- Jocelin Fitzgerald
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1 PHARMACY SERVICES Preventive Services: Covered Contraceptive Products for Oregon Find out if your medication is on the list We are committed to empowering you to know your coverage options for preventive care and make informed health care decisions. Under our Preventive Services benefit*, we cover options in each FDA approved contraceptive method category at no cost to you. Some contraceptives are available from a pharmacy (under your Prescription Medication Benefit ) while others are provided by your doctor (under your Medical Benefit ). Specifically, we cover generically available women s contraceptives. When no generic exists for an FDA-approved contraceptive method category, a brand-name women s contraceptive that is on our formulary will be covered at no cost to you. If your doctor believes that our covered contraceptives are medically inappropriate, you may request an exception by contacting Customer Service at the number listed on the back of your member ID card. *Not all plans include preventive benefits covered at 100%. Check your benefit booklet for your coverage. 2019
2 Contraceptives Available From a Pharmacy The following contraceptive products are available from an eligible retail pharmacy and will be processed under your pharmacy benefits with a prescription. Please see your health plan s website or contact Customer Service for information on eligible pharmacies. Over-The-Counter (OTC) products require a prescription from your doctor to be processed at no cost to you at the pharmacy. BARRIER METHODS: Condoms Female condom () Diaphragm Sponges Nonoxynol-9 containing Sponges, including Today Sponge () Cervical Cap Spermicide Nonoxynol-9 containing gel () NON-ORAL HORMONAL METHODS: Patch Xulane Vaginal Contraceptive Ring NuvaRing Shot/Injection Medroxyprogesterone acetate 150 mg/ml EMERGENCY CONTRACEPTION: Levonorgestrel-Containing Products Generic Products* for Plan B One-Step : Aftera, EContra EZ, Fallback Solo, Levonorgestrel 1.5mg, My Choice, My Way, Next Choice One Dose, Opcicon One-Step, React 1.5mg, Take Action Ulipristal Acetate-Containing Products Ella *Note: Because Plan B One-Step is a brand name product, it is not covered under our Preventive Services benefit. The generic products listed above are covered under this benefit and have the same active ingredient as Plan B One-Step. 2019
3 ORAL CONTRACEPTIVES (BIRTH CONTROL PILLS): Oral Contraceptive- Mini Pill/Progestin Oral Contraceptive-Combined Pill (cont.) Camila Bekyree Deblitane Blisovi FE Errin Briellyn Heather Camrese Jencycla Camrese Lo Lyza Caziant Nora-BE Cesia Norethindrone 0.35mg Chateal Norlyroc Cryselle 28 Sharobel Cyclafem 1/35 Oral Contraceptive-Extended/Continuous Use Cyclafem 7/7/7 Amethia Cyred Amethia Lo Dasetta 1/35 Ashlyna Dasetta 7/7/7 Camrese Daysee Camrese Lo Delyla Daysee Desogestrel-ethinyl estradiol Introvale Drospirenone-ethinyl estradiol Jolessa Drospirenone-ethinyl estradiol-levomefolate Levonorgestrel-ethinyl estradiol (91-day pack) Elinest Quasense Emoquette Setlakin Enpresse 28 Oral Contraceptive-Combined Pill Enskyce Altavera Estarylla Alyacen 1/35 Ethynodiol diacetate-ethinyl estradiol Alyacen 7/7/7 Falmina Amethia Gianvi Amethia Lo Gildagia Amethyst Gildess 1.5/30 Apri Gildess 1/20 Aranelle Gildess 24 Fe Ashlyna Gildess Fe 1.5/30 Aubra Gildess Fe 1/20 Aviane Introvale Azurette Jolessa Balziva Juleber 2019
4 Oral Contraceptive-Combined Pill (cont.) Junel 1.5/30 Nikki Junel 1/20 Norethindrone-ethinyl estra ferrous fumarate Junel Fe 1.5/30 Norethindrone ace-ethinyl estradiol Junel Fe 1/20 Norethindrone ace-ethinyl estradiol-fe Kariva Norethindrone-ethinyl estra ferrous fumarate Kelnor 1/35 Norethindrone ace-ethinyl estradiol Kelnor 1/50 Norethindrone ace-ethinyl estradiol-fe Kimidess Norgestimate-ethinyl estradiol Kurvelo Nortrel Larin 1.5/30 Ocella Larin 1/20 Ogestrel Larin 24 Fe Orsythia Larin Fe 1.5/30 Philith Larin Fe 1/20 Philith Layolis Fe Pimtrea Leena Pirmella 1/35 Lessina Pirmella 7/7/7 Levonest Portia 28 Levonorgestrel-ethinyl estradiol Previfem Levora 0.15/30-28 Quasense Lomedia 24 Fe Rajani Loryna Reclipsen Low-Ogestrel Solia Lutera Sprintec 28 Melodetta 24 Fe Sronyx Mibelas 24 Fe Syeda Microgestin 1.5/30 Tarina Fe 1/20 Microgestin 1/20 Tilia Fe Microgestin Fe Tri-Estarylla Microgestin Fe 1.5/30 Tri-Legest Fe Mono-Linyah Tri-Linyah Mononessa Tri-Lo-Estarylla Myzilra Tri-Lo-Marzia Necon 0.5/35-28 Tri-Lo-Sprintec Necon 1/35 TriNessa Necon 1/50-28 TriNessa Lo Necon 10/11-28 Tri-Previfem Necon 7/7/7 Tri-Sprintec 2019
5 Oral Contraceptive-Combined Pill (cont.) Trivora 28 Wera Tydemy Wymzya Fe Velivet Zarah Vestura Zenchent Vienva Zenchent Fe Viorele Zovia 1/35E Vyfemla Zovia 1/50E VyLibra Contraceptives Available From a Doctor The following contraceptive products and sterilization services are available from an eligible medical provider and will be processed under your medical benefit. Please see your health plan s website or contact Customer Service for information on eligible medical providers. BARRIER METHODS: Diaphragm Cervical Cap NON-ORAL HORMONAL METHODS: Shot/Injection Medroxyprogesterone acetate 150 mg/ml IMPLANTED DEVICES: IUD Copper Paragard IUD with Progestin Kyleena, Liletta, Mirena, Skyla Implantable Rod Nexplanon 2019
6 OTHER: Surgical Implant Surgical Sterilization Questions? Call the Customer Service number on your member ID card. 2019
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